‘The Wrong Kidney’ a short film by Steven Shorrock to explore the complexity of accidents in healthcare.
The film depicts a fictional scenario where a patient undergoes ‘wrong-site surgery’ resulting in removal of the wrong kidney. It serves as a free educational tool, offering insights into how judgements are formed in complex situations. The film is accompanied by fictional statements from various stakeholders, presenting diverse and sometimes conflicting perspectives. The post suggests various ways to use the film and statements for educational purposes inside or outside of healthcare, with practical tips on facilitating these discussions to enhance understanding of human and systemic factors in accidents and the aftermath.
When things go seriously wrong and people are harmed, there are often mixed views on what happened, how, and why, including culpability and responsibility. How we make sense of accidents and their human contributions has many influences: informational, temporal, personal, social, cultural, historical, organisational, regulatory, legal, and so on. But we can never fully understand work-as-done in a complex situation. Since work-as-done and the associated context are unknowable, we construct an understanding via proxies. These proxies and the multiple contexts of sensemaking interact to inform our work-as-imagined, combined with our imagination of context of work-as-done. It is on this that we base our judgement, evaluation or appraisal of work – work-as-judged, which has several characteristics.
For all of us, but especially those in certain professions, it is important to learn about how we make judgements, the nature of these judgements, and the effects of them. We can learn about this from books and articles of course, but a more immersive experience results in a different type of learning.
